Having braved international flights half of the team from DFTB (Andy and Henry) have made it to SMACCDub. For those of you not in the know, the Social Media And Critical Care conference is in it’s fourth year now and partly inspired us to start Don’t Forget The Bubbles. Although the editors regularly chat online this was the first time Henry and I have met in person.
In order to make the most of our time abroad we had both booked into the #SMACCmini paediatric workshop.
With a line of speakers encompassing the best and brightest from the world of paediatrics (apart from us), we were excited to see what they had to offer. With a variety of lightning, 10-minute talks over the course of the morning topics ranged from communication to caring for the critically ill child.
Natalie May was our leatherette-clad hostess and kicked off the proceedings with an update on the 2015 ILCOR guidelines. Whilst little has changed in the resuscitation of the infant it is the rare resuscitation of the newborn that scares us the most. Whilst a precipitous delivery in the department may be a rare event, it does happen. Babies may be born in less than ideal circumstances – on the leather back seat of their husband’s new car, in the toilet (literally) or in the lift up to the birthing suite – but thankfully the need to perform complex interventions is rare. We need to know what to do before help arrives. This short video may help those who are paralysed by fear
PEM literature update
Tim Horeczko took to the stage next, disguised as an event organizer. Despite technical issues that were out of his control he took us on a whirlwind tour of some paediatric literature that most of us in the room were not aware of
Approaches to spotting the sick child
The Wonder Woman of Leicester, Rachel Rowlands, then took to the stage (along with her constant companion, Norman the dinosaur) to remind us of the importance of gestalt in spotting the sick child, a theme that would be echoed by many speakers throughout the morning. She took us on a choose-your-own-adventure style quest, not to find the treasure, but to save the life of a young boy that had swallowed a button battery. If you want to know more about the dangers of these deadly discs then take a look at her video
Spotting sepsis early
Adrian Plunkett talked eloquently about the use of the NICE traffic light system and other early warning scores to predict sepsis. But really he gave us two key take-home points to lock onto:-
Be worried if there is a change of state – they are not the same as they were yesterday
Be worried if this illness is like no other illness they have ever had
By using these two key questions in the history we might become more alert to the risk of potential deterioration and look for ways to validate our fears – order the extra blood tests, and keep the child in for a period of further observation.
Sick neonates are simple
Trish Woods, a neonatologist from WA, reminded us that all neonates want is to be protected. When they are threatened, be that in the form of imminent airway or breathing difficulty, their physiology wants to return to the womb. By understanding the transition from safe, warm and comforting intra-uterine life to the harsh outside world we can guide our resuscitation.
Mistakes and pitfalls in critical care
Phil Hyde, who gave an excellent talk about the use of real children during simulation at last year’s conference urged us to use our fear, not because it leads to the dark side, but to help us step towards the stressful. We have all been in a resuscitation when there is a palpable sense of half-repressed panic. Voices are raised and critical instructions are missed, mistakes are made. But just as the emotions of the team leader can have a negative impact on the team they can also act to stop the sweating. By being the slow, smooth voice of calm the team leader can imbue all of the group with the same feeling.
This can be a challenge so there are things we can do to mitigate the internal stress. Cliff Reid talks of using the high-fidelity simulator that is our brain to visualize these high-stress scenarios before they happen. That is all when and good if you are experienced and have seen a lot of sick kids. But what do you do if you haven’t? Phil suggests visiting your local PICU and asking questions of doctors and families, stepping towards the fear. He also suggested using www.spottingthesickchild.com, a free online resource (though you need to register) to make you more comfortable in your assessment of deteriorating infants.
The southern hemispheres Wizard of the Wand, Giant of the Gel, Prince of Probes, himself – Casey Parker – demonstrated how easy it is for us all to perform lung ultrasounds on children. In just 8 minutes he reminded us that our clinical exam counts for very nought and that a normal appearing chest x-ray can be deceptive in a child that you think has pneumonia from the history. Waving the magic wand is easy and can be taught in just four minutes. It is certainly a skill that I am going to take home to my place of practice. (Ed. I’d just like to give a huge thanks to Casey for encouraging me to write after the first SMACC in Sydney and publishing my very first blog post.)
What paediatric surgeons wished you knew
The esteemed paediatric surgeon, Mr Ross Fisher of p cubed presentations, then took us through some of his personal bugbears. After learning that there is no such thing as a normal bowel habit in a child, a fact that most parents can attest to, to decrying the lack of proper physical examination prior to imaging he put us in his shoes. Surgeons have no special ability to rule out appendicitis, but often have the benefit of experience to help determine what else may be going on.
As we came towards the end of the first half of the morning Nat Thurtle reminded us that children like to put things in their mouths that no normal person would. Eschewing the usual list of one-pill kills she talked about some newer toxins that most of us would not find palatable – e-liquids, laundry detergent pods and synthetic cannabinoids. By using the powerful Resus RSI DEAD mnemonic we can have a framework with which to risk stratify and deal with any potential toxic ingestion.
As we were getting ready for our morning coffee Nat May reminded us that paediatric trauma often presents to non-paediatric centres and that we should all be able to recognize and deal with it. Mechanisms of trauma vary with age from the drunken horse-riding antics of teenagers to younger children who skateboard in front of cars. Paediatric trauma can be very confronting and how we approach our patients and their families can have a great impact on their long-term outcomes.
Appropriately caffeinated we headed back to the hall for another round of talks.
Excellence in critical care
Adrian Plunkett started off the session on a positive note. Whilst it is easy to criticise bad practice it is much harder to praise the good. He urged us to learn from the things we do well. By actively promoting best practices within your network a culture of positivity and a ‘can-do’ attitude arises. If you visit the Learning from Excellence website you can learn from others’ peer-reported episodes of excellence in practice. Similar to the ‘Awesome and Amazing’ antithesis to the monthly M&M conference we need to let others in the team know they are doing a great job.
Communication: Kids and families
We all have had occasions when we think we have done a great job with our young patients and their families. Roisin McNamara brought us down to earth with a tale of when things that she thought had gone well had been perceived very differently by the family involved. When harsh words are spoken it is important to have the emotional intelligence not to snap back, and not to get angry. Often parents are not angry at you but at the situation but the doctor in front of them is the visible face of a systemic problem. Parents may feel they are being dismissed as time wasters if time is not spent taking a thorough history and appropriate physical exam before pronouncing that their darling daughter has no medical cause for their symptoms.
Nat Thurtle returned to the limelight to talk about her time working in resource-poor settings. Those of us that work in the developed world are incredibly lucky to have access to the resources we have. As she told her moving story of almost insurmountable challenges we all stopped and reflected on how lucky we truly are
After hearing about children that don’t have access to even supplemental oxygen when it is needed Tim Horeczko talked about technology-dependent children and their complex needs. Whilst we are unlikely to encounter a child with a ventricular assist device outside of a quaternary centre we may well be exposed to children with a VP shunt, or a child that suffers from an incurable neuromuscular or mitochondrial defect. As is nearly always the case in paediatrics – the parents know best, so listen.
Ross Fisher then urged us to “Keep Calm and Carry On” when confronted with potential paediatric surgical nightmares. He reminded us time and again that we know how to do the basics – analgesia, fluid resuscitation, investigate – and that there is nothing that we should be afraid of.
Neonatal procedure tips
Having previously told us that looking after sick neonates was easy-peasy, Trish Woods then went on to teach us how. By focusing on the ABCs of resuscitation she walked us through the neonatal airway and breathing before showing some great slides and giving us all the tools we need to insert an umbilical line. At the time of neonatal resuscitation, early vascular access as a means of giving fluids and adrenaline can save a life.
This great procedural talk was followed by Tim Horeczko on his top three tips for intubating infants. We know that critical procedures are rarely performed by paediatricians let alone general emergency physicians but by adding these three things to one’s repertoire we should increase our chance of first-pass success.
Use the shoulder bump
Use the jaw thrust
Change your position and look high
Once we have successfully intubated (and confirmed tube placement with waveform capnography) Phil Hyde talked about ventilation strategies. By using PEEP and low tidal volume breaths (6-8mls/kg) we can adequately ventilate most children titrating to a pH>7.2 and an SpO2 >92%. Attention to simple things such as sedation, paralysis and monitoring can make all the difference.
The Patient experience
The final session of the day brought home to all of us in the room why we do what we do. We heard from Emer, a brave 11-year-old girl, who had spent 5 days in the ICU with tracheitis, of her experience, both in the emergency room and in the unit. Her clinical care was excellent and could not be faulted but if there was one thing she wanted us all to take away it was ‘Don’t use long medical words‘. We doctors assume a common tongue and use medical terminology as a technical shorthand with our colleagues. We occasionally slip into this mode of talking with patients and their relatives. Emer reminded us to think before we speak
The organizing committee and all of the faculty did an amazing job of fitting such a wide array of topics in such a short time frame. Never did the audience feel overwhelmed with knowledge and most of us just stopped tweeting and just listened, quietly reflected and were inspired to do better.
DFTB in Dublin – the First Day
Andy and I had flown halfway across the world to meet up in person at the Social Media And Critical Care conference in Dublin. Although touted initially as a critical care conference it is much more than that. Healthcare workers (not just doctors) from such interwoven disciplines as anaesthesia, intensive care, emergency medicine and paediatrics came together to learn, connect and be inspired.
The opening ceremony began with the pizazz and style to which SMACC delegates have been accustomed, including a Coldplay-style light show with lasers and flashing wristbands. This was followed by the John Hinds Plenary session featuring;
Victoria Brazil‘s talk ‘So, you think you’re a resuscitationist…’ dissected the art and science of improving. In particular, she espoused the importance of giving and eliciting feedback, doing so often, and doing it with compassion and honesty. She wanted us to be the mirror and elicit perceptions.
Scott Weingart podcasted live from the SMACC auditorium about the ‘Kettlebells for the Brain’ that are meditation. He introduced the SMACC auditorium to the concepts of mindful meditation and negative visualisation in a powerful presentation and moving talk.
“Exercise is work to make you live longer; meditation is work to make you live better.“
Gareth Davies of London HEMS proposed the ‘Case for Helicopter Emergency Medical Services‘, reinforcing the importance of clinical excellence accompanying the inherent ‘sexiness’ that helicopters bring to pre-hospital care. He encouraged us all to practice medicine ‘full bore’ – not going off half-cocked but providing maximum quality care to all.
The session was brought to a close with a fitting and beautiful tribute to Dr John Hinds, SMACC-alumnus, pre-hospitalist, anaesthetist and motorcycle doctor extraordinaire who tragically died last year.
My choice of concurrent for the morning was ‘Emergency!’, opened by the astute Simon Carley presenting the future of Emergency medicine with a focus on the people, the politics and the possibilities of rapid technological progress. He made some big calls about the future of bioinformatics and personal health.
Subsequently, the ever-elegant Michelle Johnston juxtaposed Carley’s utopia with an equally possible dystopian future, potentially attributable to the small decisions we make each day. Journeying through Philip K. Dick’s world of replicants and Voight-Kampff tests, Winston Smiths’ image of the future as ‘a boot stamping on the human face, forever’ and Terry Gilliam’s bureaucratic fever dream, Brazil, we saw what life could be like. Multiple small, seemingly insignificant decisions, when combined could lead us down an irreversible path of excessive tests, unstable economics, and physical and bureaucratic waste. Choose wisely.
Suzanne Mason gave a talk about frailty and geriatrics, and for me, the take-home message as it pertains to paediatrics is that we need to learn to love and understand our most frail patients, particularly kids with transplants, GMFCS4+ cerebral palsy or refractory seizure disorders with or without profound disability. They don’t present for nothing; they already spend too much time in the hospital. Frail patients generally cope less well with admission and so it pays to think hard before admitting these kids “just in case”.
In the always challenging ‘last presentation before lunch’ spot Anand Swaminatham discussed the notion of thin slicing in the ED – specifically knowing and understanding the spectrum and severity of the disease. That is, we should call a disease what it is, every time. This includes a modifier including severity. By this construct, we are encouraged not to minimise the severity and hence escalate the management to match.
One of the other themes echoing throughout the conference has been Daniel Kahneman’s seminal work “Thinking, Fast and Slow”; which introduces the idea of System 1 (rough, ready, intuitive, heuristic) and System 2 (contemplative, analytical, reflective, questioning) thinking.
Afternoon Concurrent and Panel Discussion
The afternoon focussed on research and publication.
Firstly, I attended the concurrent including Richard Smith the ex-editor of the BMJ, and Jeff Drazen current editor of the @NEJM included a spirited discussion on the role of the big journals in medicine. This session also included an eloquent explanation of the merits of the (in)famous p-value as well as introducing the concept of the fragility index – a full explanation is beyond the remit of this post, but if you read one bio stats piece of analysis this year, I’d make it on this.
After the tea break, the last session of the day continued the editors’ spirited discussion to a ten-person panel, answering such questions as;
- What conventional publishing, as opposed to social media, offers to medicine and research?
- What works for trainees (there was one on the panel.)
- A discussion about the pressure of publication and impact factors.
- The panellists were asked about the role of major journals and equality of representation within author and editor groups.
- Finally, there was a continuation of the previous session’s robust and forthright discussion on the merits of conventional literature and the role of peer review.
The main message of the session, as emphasised by Drs Carley and Myburgh, is that research is about improving patient outcomes, not careers, not impact factors, not about egos. With each item of information, we must continue to seek better care for our patients.
DFTB in Dublin – the Second Day
Small children prevented Henry and me from spending too much time out in the town enjoying what Dublin has to offer. One advantage of this was that we were both able to enjoy the morning sessions without the hangovers that so many of our friends and colleagues had.
The theme for the morning plenary session was “Slaying Sacred Cows”. Four excellent speakers took the time to challenge long-held beliefs and make us question some of our ingrained ideas.
Leadership: not (just) for men
Resa Lewiss began by talking about leadership. To some of us, the word ‘leader’ conjures up images of old white men with power ties and masculine poses. Resa reminded us that over half the medical population are women and it is time for us to realise this. Just as we have seen #Ilooklikeasurgeon trend worldwide she wanted to trend #IIlooklikealeader. With many strong leaders in the world of paediatrics, this is something that we at Don’t Forget The Bubbles support wholeheartedly. SMACC has tried hard this year to ensure gender equity with the speaker panel and this is one of our core aims for #DFTB17.
Resa had the following tips for those that want to inspire and lead:-
Praise in public, criticise in private
Make decisions – don’t be indecisive
Concentrate on your strengths and let others cover your weaknesses
Make people feel good about themselves
If you don’t ask you don’t get
As someone who is an extreme introvert, it was this final point that really made me reflect. Nat May has already written a superb post on impostor syndrome but it is worth remembering that there is power in breaking free of the self-imposed shackles of quietude and putting yourself out there and just asking for help.
Things that scare me
Paediatric surgeon and presentation skills guru Ross Fisher showed why he is so well respected as a speaker. Eschewing supportive media he took to the stage to speak about fear. Over the course of twenty minutes, he spoke about some of the times in his life in which he had been truly scared. Not the sort of fear you get riding on an out-of-control roller-coaster but the sort of deep, visceral fear that makes your mouth dry up, your head pound and your legs shake. By the end of his talk there was barely a dry eye in the house (or on the stage). This is a must-watch talk when it comes out and is the one that really made me just stop and think.
Emergency management of the agitated patient
Reuben Strayer concentrated on something that we don’t see very often in the emergency department. We do occasionally have to deal with agitated teens and it’s worthwhile looking at this alternative take.
What’s love got to do with it?
The morning was topped off by the fabulous Liz Crowe. She reminded us that we obviously all love our jobs – most of us seem to spend over a third of our lives there – but like any relationship, we can have good times and not-so-good times. Just as any marriage takes effort to make it work the same is true for our relationship with our job. We need the support of our work husbands and wives when times are tough and to remind us of those times when we basked in the afterglow of our first successful resuscitation.
And whilst we love our jobs Liz reminded us that we must also love our patients. We must treat them all with kindness and compassion. They did not, would never, choose to be in the hospital. We must always, always remember that. A kind word, a cup of tea, and a warm blanket go a long way.
Later that same day…
After coffee, we broke up for our concurrent sessions. I went to the session entitled “Time to gas, time to cut”. Karim Brohi spoke about Zen and the Art of Trauma, again reinforcing the need for the leader to be the centre of calm. That calmness is infectious. We’ve heard about tools we can use in the moment to help us regain calm but Karim reminded us that calmness is a learned behaviour. It is paying attention to minor details, and reducing errors and variances in the system. It is understanding when less is more, that some patients do not need every conceivable test but only the necessary tests to get them to theatre. And it is mentally rehearsing for every possible outcome.
And whilst some of the talks may seem heavy, the morning session was completed by the (not safe for work) Suman Biswas.
DFTB in Dublin – the Final Day
By means of performance-enhancing substances (caffeine), we made it to the final sessions of #SMACCdub – voices somewhat subdued by trying to converse at the gala dinner, held in the historical Guinness Storehouse. The pains of struggling bandwidth were ameliorated by a drop in attendance.
An all-female panel took to the stage for the first plenary of the morning on moving ‘Beyond the Ivory Towers’.
Emergency interventions in African children: What next?
The internationally renowned author of the FEAST trial, Kathryn Maitland, began the morning by reminding us of the enormous burden of disease in sub-Saharan Africa. With up to 70% of pneumonia-related deaths occurring in SE Asia and Sub-Saharan Africa, there is a clear need for simple, pragmatic guidelines to improve mortality. Resources that we take for granted such as monitoring and oxygen therapy are in low supply. With clinical signs, a poor indicator of the need for ongoing oxygen supplementation a number of inappropriate children receive supplemental oxygen. Initiatives like Lifebox may help.
Whilst there is a state of equipoise in the use of oxygen therapy in such a population it is an area ripe for study. But oxygen is expensive and can take up to half of Professor Maitland’s drug budget and so nurses have to become resourceful. It must also be pointed out that oxygen alone cannot fix ventilatory failure.
Critical care in difficult contexts
Nikki Blackwell of Brisbane and ALIMA then came on stage to tell us what it is really like working in a resource-poor setting. Working in environments ravaged by war, disease and hunger emergencies (there is food but not in the right places) she has seen a rise in ‘humanitarian action as a response to political failure‘.
“The key is bringing up healthy, well adjusted people that care about justice and social equity” Nikki Blackwell
With fewer resources available there are fewer problems with iatrogenically introduced disease and children can have remarkable recoveries once attention is paid to the basics such as hygiene and nutrition. By making their own hand gel sanitiser they were able to drop infection rates and also increase buy-in – a problem that we all face. She also described how African mothers were able to assess their own children for malnutrition and that by using locally made products such as PlumpyNut – a combination of peanut butter and milk powder – huge gains could be seen for a few cents.
We need palliative care everywhere
Ashley Shreves, an emergency physician with a passion for palliative care told us her origin story and spoke about how the ever-revolving cast of players can derail one person’s perfectly constructed end-of-life plan. Having reinforced the concept of having a good death it is worthwhile reflecting on Greg Kelly’s superb talk from SMACC Gold.
The Golden Fleece, The Golden Hour and The Golden Rule
Following on from last year’s talk on looking after ourselves Ashley Liebig bravely described how he completely went against her own advice after dealing with a heartbreaking paediatric trauma. We are all consummate professionals but sometimes a misjudged word can throw our world into a tailspin. We need to be kind to our colleagues, and ourselves. Often those that work in Ivory Towers have no concept of what life is like ‘out there’ – be it in a small country hospital or at the roadside. So the next time you think to yourself, “Why didn’t they do….?” just stop. They may not have the resources or the skills available to do the things you almost take for granted. Put yourself in their shoes for once and…
“Treat others how you would like to be treated yourself”
After catching up with friends both old and new Henry and I took the stairs to the paediatric session, chaired by Nat May.
Should we transfuse the sick child in Africa?
After her earlier talk on oxygen therapy, Kath Maitland moved from breathing to circulation and the role of blood transfusion in Africa. As well as pneumonia, profound anaemia (Hb <6g/dl) is another cause high of mortality in sub-Saharan Africa with up to 10% of children dying in hospital as a result and a further 12% dying in the six months after admission. This anaemia is multifactorial with sickle cell disease, infection and nutritional deficiencies all playing their part.
The ongoing TRACT trial looks to see what volume, if any, of blood makes a difference. With current WHO guidelines suggesting transfusion at haemoglobins less than 4g/dl (or 6g/dl in the presence of comorbidities), there is little relevance to patients in the developed world but this is still very important work indeed. We expect to hear some answers in the next few years.
Spotting the sick child
As we discussed at the pre-conference paediatric workshops it can be near impossible to spot a sick child. We are all scared by what we may miss and Simon Judkins recounts one such event in Real ED stories. Sure we could rely on tests and biomarkers but in the end speaker, Ffion Davies urges us to go back to basics and think of the physiology of the child. It is easy to try and rationalize abnormal results but tachypnoea is the most sensitive sign of badness. Doctors often just look at the admission observations but we remember “Observation is an intervention” and get them checked more than once and be very wary of sending home a child with abnormal vital signs.
Whilst biological parameters such as pulse, blood pressure or oxygen saturation are almost fixed with little room for interpretation what is more problematic is how we think when dealing with children. The majority of the kids we see in the emergency department are well so our immediate cognitive disposition to respond assumes that every child we see is well rather than considering the worst possible outcomes. Remember that children are just little adults (though babies are another species entirely) and are incredibly resilient. If a child appears well they probably are and if they appear sick they certainly are but it is those children in the grey zone that Ffion focuses on.
Iconoclasm: Breaking the myths without breaking your patient
The only man on in the session (minus Casey Parker moderating), Tim Horezcko, took the stage to bust some paediatric myths – or pediatric myths as he spells them. He really elucidated what all of us really felt inside.
Small Packages, Big Lessons: Neonatal and paediatric retrieval
The final talk of the morning was by EMBRACE consultant, Hazel Talbot (Ed. note COI to declare Hazel was two years below me at the best medical school ever – CXWMS). She told us that babies are not small children but an entirely different species that try to survive no matter what we do. She explained the concept of the evil fairy that sneaks into the back of every helicopter or ambulance when we go on a retrieval mission with the sole intention of creating chaos where once there was calm. She is not so powerful when the team have rehearsed together practising accidental intubation drills in the back of an ambulance but she is always ready to sprinkle some fairy dust on the child and muck things up. But remember sometimes it is not the equipment that is wrong but the child.
Both Henry and I met some wonderful people over our four days in Dublin. We finally met people we have been chatting with online for years and would happily call out friends. We met people we have never met before but who inspired us both. And we finally said hello in person.